A nurse palpates a client's radial pulses bilaterally and notes the client's right radial pulse is bounding, and the client's left radial pulse is as expected. The client's heart rate is 80/min. Which of the following documentations should the nurse make?

Right radial pulse 4+, 80/min, palpated

Left radial pulse 1+, 80/min, palpated

Left radial pulse 4+, 80/min, palpated

Right radial pulse 2+, 80/min, palpated

Answer and Explanation

The Correct Answer is A

A. Right radial pulse 4+, 80/min, palpated:
A 4+ pulse is bounding, which is consistent with the nurse’s finding. HR is documented as 80 bpm.

B. Left radial pulse 1+, 80/min, palpated:
There is no indication that the left pulse is weak or thready (which would be 1+).

C. Left radial pulse 4+, 80/min, palpated:
The left radial pulse was described as expected, not bounding.

D. Right radial pulse 2+, 80/min, palpated:
A 2+ pulse is considered normal, but the right pulse was bounding, which corresponds to a 4+ rating.

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Correct Answer is B

Explanation

A. Hydrofiber dressing:
Hydrofiber dressings are designed for moderate to heavy exudate, not dry or non-exudative wounds.

B. Transparent-film dressing:
Transparent-film dressings are ideal for superficial, non-draining wounds like skin tears. They protect the area while allowing for oxygen exchange and visualization of the wound.

C. Alginate dressing:
Alginate dressings are highly absorbent and used for moderate to heavy exudating wounds, not for dry superficial tears.

D. Foam dressing:
Foam dressings are best for wounds with exudate. They are thicker and may not adhere well to superficial skin tears without drainage.

A. Place a gauze pad around the drain. B. Connect the drain to continuous low-pressure suction. C. Clean the skin near the drain in a circular motion from the outside to the inside. D. Empty the drainage device when it is half full.

Correct Answer is A

Explanation

A. Place a gauze pad around the drain:
Penrose drains are open and passive. A gauze pad absorbs drainage and prevents skin irritation or maceration around the site.

B. Connect the drain to continuous low-pressure suction:
Penrose drains are not connected to suction. They allow drainage to passively exit the wound.

C. Clean the skin near the drain in a circular motion from the outside to the inside:
The correct method is to clean from the drain outward, to prevent contaminating the site.

D. Empty the drainage device when it is half full:
Penrose drains do not have a collection device to empty; instead, drainage is absorbed into gauze.

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A nurse palpates a client's radial pulses bilaterally and notes the client's right radial pulse is bounding, and the client's left radial pulse is as expected. The client's heart rate is 80/min. Which of the following documentations should the nurse make?

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Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has a superficial skin tear with no exudate. Which of the following dressings should the nurse recommend to cover the wound?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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